Proposal to Mandate Condom Distribution in Prisons Would Reduce Correctional Facility Costs for Inmate Health Care in California

What is the potential impact of the proposed bill (AB999, Bonta) mandating the California Department of Corrections and Rehabilitation to make condoms available to inmates in its 33 California prisons?

In response to a newly released report on the pilot program that evaluated condoms distribution in one of the four Solano State Prison facilities >(Lucas, 2011), California Assembly Member Rob Bonta recently proposed AB999, which would require the California Department of Corrections and Rehabilitation (CDCR) to develop a five-year plan to make condoms available in all California prisons. AB999 would instruct CDCR to use funds from its budget to provide condoms and condom dispensing machines at all California prisons by December 2019. It would encourage facilities to consider also allowing prisoners to request condoms privately from prison medical and mental health care providers and would require condom program planning and implementation to include input from inmate peer educators and advisory councils, medical, public health, and custody staff.

There are currently over 124,000 individuals housed in California prisons on any given day, of whom over 95% are males. The mean length of stay is 22 months and close to 60% return within two years of release (CDCR 2011). None currently have access to condoms — a public health HIV/STD prevention tool that the World Health Organization and the United Nations Programs on HIV/AIDS recommend be made available in custody settings.

Review of findings from evaluations of condom distribution programs in California correctional institutions and brief analysis of potential HIV infections averted in CA prison by AB 999.

Solano Prison Pilot Program

The California Correctional Health Care Services (CCHCS), Public Health Unit (PHU), in collaboration with the California Department of Public Health, Office of AIDS (OA), and Sexually Transmitted Diseases (STD) Control Branch, evaluated the risk, feasibility, and cost of a one-year (11/08 to 11/09) pilot program of condom distribution to inmates at Solano State Prison Facility II (Lucas, 2011). Based on reports of the numbers of condoms dispensed each week, the costs of distribution, a comparison of the rule violation reports for the pre-pilot and pilot periods and surveys of inmates (n=26 pre and 25 post) and jail staff (n=114 pre and 55 post), the authors concluded:

1. An average of 30 condoms were distributed per week in a facility with an average daily population of 810.
2. There was no evidence that providing condoms posed an increased risk to safety and security or resulted in injuries to staff or inmates.
3. Serious condom-related safety or management issues are rare.
4. Dispensing machines provide a feasible and relatively low cost method of condom distribution
5. Providing condoms would likely reduce the transmission of HIV, STDs, and hepatitis in CDCR prisons, thereby reducing medical costs in both CDCR and the community.
6. The first year start-up cost including dispensers, condoms, and staff time was estimated at about $1.50/inmate and the program’s annual cost at $0.75/inmate. This compares to the average annual cost of treating one HIV patient ($40,800).
7. Very few HIV infections (2.7 to 5.4 per year) would need to be prevented for the program to be cost-neutral.

San Francisco Jail condom distribution program

The San Francisco jail system has used a condom dispensing machine to make condoms available to its male inmates since 2007. A 2007 evaluation (Sylla et al. 2010) compared using a condom dispensing machine with the health-educator distribution system that had been used between 1989 and 2007. The comparison of pre-/post- data from the four-month pilot found:

1. Availability of condom dispensing machines increased both prisoners’ awareness of their legitimate access to condoms and their likelihood of obtaining condoms.
2. Particularly large increases in knowledge about and use of the condom access programs occurred among those who were HIV infected or in a high-risk group.
3. Sexual activity did not increase, custody operations were not impeded, and custody acceptability of condom access for prisoners increased.

Los Angeles Jail condom distribution program

The Los Angeles Sheriff’s Department began allowing distribution of one condom a week to interested inmates in a segregated unit for self-identified men who have sex with men and male-to-female transgenders in 2001. Inmates were surveyed about their sexual activity and condom use before and after condom distribution began in 2001, and again in 2007. Interviews were conducted with 10 line and administrative staff regarding the program.

1. Over half of those surveyed in 2007 (53%) reported anal sex during custody in the prior 30 days. Of these, 65% reported using condoms and 49% of their reported anal sex acts were not condom protected (Harawa et al., 2010).
2. Compared to rates of unprotected anal intercourse in the absence of condom availability, the condom distribution program averted 25% of potential in-custody HIV transmissions each month. (Leibowitz, et al 2012).
3. Society’s future discounted medical costs averted due to having fewer HIV transmissions far exceed the cost of the program, so condom distribution in jail is cost-saving to society. (Leibowitz, et al 2012).
4. Cost savings were sensitive to the proportion of anal sex acts protected by condoms, thus allowing access to more than one condom per week could potentially increase the program’s effectiveness (Leibowitz et al., 2012).
5. Condom use in jail can also avert the transmission of large numbers of STIs at a low net cost and at a potential cost savings. (Tuli and Kerndt 2008)
6.  There is general staff acceptance of the Los Angeles program because of its potential public health benefits.
7. Staff did not report jail safety or management issues related to condom availability or the program’s design. However, some expressed concerns about the mixed message sent by condom availability in a context where sex is barred (McCuller & Harawa, under review).

Although data indicate that most HIV-positive prisoners in the US likely entered prison already infected with HIV (Harawa, NT & Adimora A, 2008), both HIV/STD transmission and sexual activity have been well documented in prison settings. (Brodsky JL. et al., 2012; Mutter et al., 2006, Krebs & Simmons, 2002; Macher et al., 2006; Macalino et al., 2004).

No population-based estimates are available on the prevalence of consensual sexual intercourse among California prison inmates, and the estimates from the Los Angeles Jail unit for MSM likely overstate the rates of anal intercourse for a general prison population. A small study of prisoners in one CA medical prison facility found that 4.6% of HIV-negatives reported ever having anal sex in custody (Lucas, 2007). Recent population-based studies in English and Australian prisons have found that 2.0-3.6% of prisoners report ever engaging in consensual anal sex while in prison (Green 2003; Butler 2013)

If we conservatively assume that three percent of California prisoners engage in anal sex, that 51 percent of their sex acts are protected by condoms (when condoms are available), as was found in the Los Angeles study, and that the seropositivity rate of prisoners is 1.1 percent, there would be 2,242 California prisoners at risk of HIV infection (sexually active and HIV-negative). If we further assume that each of these at-risk prisoners has the number of sexual encounters observed in the Los Angeles study, we predict there would be 14.4 new HIV transmissions per year when condoms are not available, and 6.9 new infections if condoms are available. Thus, making condoms available to California prisoners is predicted to avert 7.5 new HIV infections, well above the 2.7-5.4 infections that the evaluation of the Solano program estimated would be needed to assure that condom distribution in prisons was cost-saving in the first year. Results for the condom distribution program would be even more positive after the initial one-time costs of initiating the program had been paid.

The findings from three California condom distribution programs are consistent with evaluations of condom distribution programs in other custody settings that have found that following implementation,

1. Condom distribution is accepted by a majority of inmates and correctional facility staff
2. Inmates’ sexual activity and drug use do not increase (Butler, 2013)
3. Serious condom-related safety or management issues do not occur
4. Condom distribution would result in fewer HIV infections and a reduction in other STIs.
5. Under most plausible assumptions, the number of HIV infections averted would easily meet the conservative criteria set by the Solano analysis for a program that reduces prison costs. In addition, the program would reduce societal costs upon the prisoners’ release.

• Bureau of Justice Statistics. HIV in Prisons, 2001-2010. Office of Justice Programs. September 2012. NCJ 238877.
• Brodsky JL., Samuel MC., Mohle-Boetani JC., Ng RC., Miller J., Gorman JM., Espain G., Bolan G. Syphilis Outbreak at a California Men’s Prison, 2007-2008: Propagation by lapses in Clinical Management, Case Management, and Public Health Surveillance. Journal of Correctional Health Care. 2012. 19 (1). 54-64. DOI: 10.1177/1078345812458088
• Butler T., Richters J., Yap L., Donovan B. Condoms for prisoners: no evidence that they increase sex in prison, but they increase safe sex. Sexually Transmitted Infections. 2013. DOI: 10.1036/sextrans-2012-050856.
• California Department of Corrections and Rehabilitation (CDCR). California Prisoners. Accessed May 7, 2013 at: http://www.ccr.ca.gov/Reports_Research/Offender_Information_Services_Branch/Annual/CalPris/CALPRISd2010.pdf
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• Lucas KD., Miller JL., Eckert V., Goldsby S., Henry MC., Samuel MC., Mohle-Boetani JC. Evaluation of Prisoner Condom Access Pilot Program conducted in one California State Prison Facility. Public Health Unit, California Correctional Health Care Services. 2011. http://www.cdph.ca.gov/programs/std/Documents/SBD%20Pilot_Final%20Report_122210-CDPH-CCHCS_September2011.pdf
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• McCuller WJ., Harawa NT., A Condom Distribution Program in the Los Angeles Men’s Central Jail: Sheriff Deputy’s Attitudes and Opinions. (Under Review). Journal of Correctional Health Care.
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• Tuli Karunesh, Kerndt Peter R Preventing sexually transmitted infections among incarcerated men who have sex with men: a cost-effectiveness analysis. Sexually Transmitted Diseases. 2009; 36(2 Suppl): S41-8.
• Lucas KD, Horne RL, Bick JA. Sexual and drug-using HIV risk behaviors among incarcerated African American and white males. International Society for Sexually Transmitted Disease Research. July 28 – August 1, 2007, Seattle, WA (poster presentation)

Funding for this research was provided by the California HIV/AIDS Research Program (Grant Number RP11-LA-020 and RP11-APLA-022)